Airway Adventures of Airtraq: Use of Airtraq Optical Laryngoscope with Adaptor in Infants with Obstructive Hydrocephalus Posted for Endoscopic Third Ventriculostomy

Published online: 2020-03-14 THIEME 126 CaseUse of Report Airtraq Optical Laryngoscope with Adaptor in Hydrocepahlic Infants Undergoing ETV Ali et al.

Shahna Ali1 Hassan Rashid1, Obaid A. Siddiqui1 Manazir Athar1

1Department of Anaesthesiology, Jawaharlal Nehru Medical College Address for correspondence Obaid A. Siddiqui, MD, Department and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh India Muslim University, Aligarh, Uttar Pradesh, India (e-mail: [email protected]).

J Neuroanaesthesiol Crit Care 2021;8:126–129.

Abstract The pediatric airway is a challenge for the anesthetist due to difficulty in adequate assessment, scarcity of management algorithms, lack of precise knowledge regarding incidence, as well as limitations of the various devices, instruments, and video laryngoscopes. We present a case series of infants with obstructive hydrocephalus with antic- Keywords ipated difficult intubation posted for endoscopic third ventriculostomy (ETV) in whom ► Airtraq the airway was successfully secured using Airtraq optical laryngoscope with adaptor. ► endoscopic third Although this device has not been widely studied in pediatrics age group, there are ventriculostomy different sizes available for use among children. The ease of use, short learning curve, ► obstructive low cost, single use, and successful approach to difficult airway have made it to being

hydrocephalus the main rescue technique when the initial approach has failed.

Introduction has been made freely available on Google play (for Android) and Application Store (for iPhone). It works along with a Hydrocephalus makes airway management challenging specially designed adaptor (A-308) for smartphone man- mainly due to the increased circumference of head, difficulty ufactured by Prodol Meditec Limited, Zhuhai, Guangdong, in positioning for intubation, and other associated congenital China. Airtraq is distributed through the worldwide AIR- anomalies. The probability of hypothermia along with rise in TRAQ distributors’ network (Prodol Meditec SA; Las Arenas, intracranial tension (ICT) may lead to herniation, respiratory Spain; ►Fig. 1). and cardiac arrest, and possibly death during management of We report a series of eleven infants with obstructive 1 hydrocephalic infants. hydrocephalus posted for endoscopic third ventriculostomy These days, a variety of video laryngoscopes are available (ETV) who were successfully intubated using Airtraq with for managing anticipated difficult airway, but experience and smartphone adaptor. familiarity with the device used are certainly more import- ant than the actual device itself. There are scarce case series available on the use of pedi- Case Series atric Airtraq in hydrocephalic infants. The pediatric Airtraq After obtaining written informed consent, 11 infants under optical laryngoscope is an airway device, which facilitates 1 year of age, who presented with obstructive hydrocepha- tracheal intubation in infants having both normal, as well lus and were scheduled for ETV, were selected for this case as difficult airways. An application (Airtraq mobile by series. Data regarding age, sex, congenital anomalies, and Airtraq) that allows live picturing of the intubation process any neurological deficit were noted.

Published online DOI https://doi.org/ © 2020. Indian Society of Neuroanaesthesiology and Critical Care. March 14, 2020 10.1055/s-0040-1701800 This is an open access article published by Thieme under the terms of the Creative ISSN 2348-0548. Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/). Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India Use of Airtraq Optical Laryngoscope with Adaptor in Hydrocepahlic Infants Undergoing ETV Ali et al. 127

Pediatric Airway Score (COPUR; ►Fig. 2). This scale rates chin size, interdental opening, previous intubation or OSA, uvula visualization, and estimated range of motion of neck on a four-point scale. Scores above 10 predict difficult intubation. A standardized protocol for anesthesia was maintained for all cases. Airtraq intubation was achieved by an experienced and skilled anesthesiologist (>50 uses). All children were kept nil per mouth as per standard guidelines. They were premedicated with atropine 0.02 mg/kg intravenously (IV), dexamethasone 0.5 mg/kg IV, and fentanyl 2 µg/kg IV in the OT, and standard monitoring including pulse oximetry, electrocardiogram (ECG), noninvasive blood pressure recording, and temperature monitoring were established. The infants were positioned with a shoulder roll, the head (occiput) was laid on a thin head ring while the body allowed to rest on the stack, so as to align the glabela horizontally with the chin, the external auditory meatus (EAM) with suprasternal notch (SN), and neck wide open. Preoxygenation was adequately provided with 100% oxygen through a face mask, followed by anesthetic induction with

inhalation of 8% sevoflurane in 50% nitrous oxide (N2O) and

50% oxygen (O2), the inspired concentration was reduced to 4% when pupils diverged. Centralization of pupils and absence of hemodynamic response to jaw thrust were deemed to con- firm adequate depth of anesthesia for intubation. None of the infants received muscle relaxants prior to intubation. An infant Airtraq laryngoscope (size zero) with adaptor was introduced midline into the oral cavity over the tongue base and the tip placed in the vallecula. Trachea was intu-

bated with age appropriate uncuffed endotracheal tube in the first attempt after centralizing the vocal cord in the proximal view finder, which required slight adaptation of Airtraq and Fig. 1 Airtraq mounted on universal adaptor for smartphone. wrist movements pulling the Airtraq back and up (►Fig. 3). Correct positioning of endotracheal tube was confirmed by A thorough preoperative evaluation was done including the capnography and chest auscultation bilaterally. Anesthesia possibility of other congenital and genetic anomalies, and neu- was maintained with 1 to 2% sevoflurane and 60% N2O in O2. rologic deficits, as well as any signs of raised intracranial pressure We used Airtraq with adaptor in difficult airway cases, (frontal bossing, dilated scalp veins, and cranial nerve palsies). following the same recommendations as applied for direct Routine laboratory results were obtained along with CT scan. laryngoscopy, implying that no more than two attempts were None of the infants had any associated congenital anomalies. made with the same device. Maneuvering techniques such Demographic and airway assessment records are as the use of introducers or intubation guides at the time of depicted in ►Table 1. The Mallampati grading was difficult insertion2,3 and external laryngeal manipulations were used to assess, and airway assessment was done by Colorado according to Fremantle’s score (►Fig. 2).4

Table 1 Demographic and airway assessment data Case Age (mo) ASA status Weight (kg) COPUR score Freemantle score view Fremantle score ease Expert satisfaction 1 08 I 6.2 6 F 1 1 2 11 II 9 9 F 1 1 3 12 I 11 8 F 1 1 4 09 I 5.3 9 F 1 1 5 07 II 8 9 F 1 2 6 08 II 13 12 P 2 2 7 09 I 10 8 F 1 1 8 11 II 8.2 10 F 1 1 9 12 II 8 7 F 1 1 10 09 I 9 10 P 2 1 11 10 II 8.2 12 P 2 1 Abbreviations: ASA, American Society of Anaesthesiologists; COPUR, Colorado pediatric airway score; F, full view; P, partial view.

Journal of Neuroanaesthesiology and Critical Care Vol. 8 No. 2/2021 © 2020. Indian Society of Neuroanaesthesiology and Critical Care. 128 Use of Airtraq Optical Laryngoscope with Adaptor in Hydrocepahlic Infants Undergoing ETV Ali et al.

Expert satisfaction about device adaptor was rated rang- Discussion ing from 1 to 4 (1 = better than without adaptor and useful; 2 = normal, not different than without adaptor; 3 = worst; Congenital hydrocephalus is commonly associated with and 4 = extremely worst/worse and inutile). Arnold–Chiari, myelomeningocele or Dandy–Walker malformations, arachnoid cysts, and vascular malformations. Acquired

Fig. 2 Freemantle scores in pediatric population.9 CT, Cormack Lehane; POGO, percentage of glottis opening; TT, tracheal tube.

Fig. 3 View of Airtraq with adaptor video laryngoscope.

Journal of Neuroanaesthesiology and Critical Care Vol. 8 No. 2/2021 © 2020. Indian Society of Neuroanaesthesiology and Critical Care. Use of Airtraq Optical Laryngoscope with Adaptor in Hydrocepahlic Infants Undergoing ETV Ali et al. 129 hydrocephalus may be a consequence of infection, intraventric- Conclusion ular hemorrhage, trauma, and tumors.5 Anesthetic management for patients with obstructive The successful execution of anticipated difficult intubation hydrocephalus posted for ETV poses specific challenges; air- largely depends on adequate preoperative evaluation, assess- way management in small patients with large heads along ment, planning, preparation, and finally execution. with anatomical and physiological differences, maintaining This case series highlights the utility of Airtraq with adequate cerebral perfusion, and preventing rise in ICT during smartphone adaptor in infants with hydrocephalus with the surgery, especially during intubation and endoscopy. known difficult airway. The authors are of the opinion that A large occiput, in these patients, places the neck in extreme intubation with this device is a better and more feasible flexion and large forehead may obscure the view of laryngos- alternative for known difficult intubations in any hospital copy. Therefore, optimum position was made, so as to align setting, mainly in developing countries where resources are glabela horizontally with the chin, the EAM with SN, and the scarce. It can be used as an effective primary technique or neck wide open. Securing the airway in a timely and effective rescue device in patients of anticipated difficult airway as in manner is a priority in these patients due to respiratory prob- infants with obstructive hydrocephalus. lems secondary to laryngospasm, bronchospasm, and hypoxia. Conflict of Interest Airtraq, an indirect laryngoscope has an optical channel None declared. accommodating a series of lenses, prisms, and mirrors that reflect the magnified image from the tip of the blade to the viewfinder.6 It has a channel in which the endotracheal References tube is loaded and advanced. Since direct line of sight is not 1 Faghih Jouibari M, Baradaran N, Shams Amiri R, Nejat F, El required, there is neither need to displace the tongue nor that Khashab M. Huge hydrocephalus: definition, management, of the sniffing position. and complications. Childs Nerv Syst 2011;27(1):95–100 The Airtraq allows better glottis visualization than direct 2 Xue FS, Yuan YJ, Wang Q, Liao X. Laryngoscopes with a guiding channel cannot avoid difficulty in passing endotracheal tube 7 laryngoscopy. It demands special consideration because through the glottis. Acta Anaesthesiol Scand 2011;55(1):134 of its easy maneuvering, low cost, and more rapid learning 3 Holm-Knudsen RJ, White J. The Airtraq may not be the solu- curve.6 There are two sizes of pediatric Airtraq available: tion for infants with difficult airways. Paediatr Anaesth infant (endotracheal tube size, 2.5–3.5 mm ID) and child 2010;20(4):374–37 (endotracheal tube size, 4.0–5.5 mm ID).8 4 Swann AD, English JD, O’Loughlin EJ. The development and pre- liminary evaluation of a proposed new scoring system for vid- The use of smartphone has gradually become popu- eolaryngoscopy. Anaesth Intensive Care 2012;40(4):697–701 9 lar among anesthesiologists. The addition of smartphone 5 McAllister JP II. Pathophysiology of congenital and neonatal to an Airtraq provides a high-quality view, allowing image hydrocephalus. Semin Fetal Neonatal Med 2012;17(5):285–294 recording, editing, analysis, and sharing for teaching purpose, 6 Holm-Knudsen R. The difficult pediatric airway–a review of without changing the line of sight.10 However, with regard new devices for indirect laryngoscopy in children younger to recording of patient data on a smartphone, legal issues than two years of age. Paediatr Anaesth 2011;21(2):98–103 7 Ranieri D Jr, Filho SM, Batista S, do Nascimento P Jr. Com- should be considered. parison of Macintosh and Airtraq laryngoscopes in obese In our case series, we have attempted to prove that the patients placed in the ramped position. Anaesthesia Airtraq with adaptor may be an alternative to intubation 2012;67(9):980–985 with video laryngoscopy, especially in the developing coun- 8 White MC, Marsh CJ, Beringer RM, et al. A randomised, con- tries. Advantages of Airtraq with adaptor are that it works trolled trial comparing the Airtraq optical laryngoscope with as a videolaryngoscope, its feasibility, ease of assistance and conventional laryngoscopy in infants and children. Anae sthesia 2012;67(3):226–231 guidance. We found 8 of 11 (72.7%) full Freemantle score in 9 Dasari KB, White SM, Pateman J. Survey of iPhone usage among our patients. According to the expert opinion, 9 of 11 (81.8%) anaesthetists in England. Anaesthesia 2011;66(7):630–631 patients rated it as useful and better than without the adap- 10 Low D, York B, Eisses MJ. A novel use for the Apple (4th tor. Intubation using Airtraq with smartphone adaptor thus generation) iPod touch in the operating room. Anaesthesia improved the visualization of the vocal cords and provided 2011;66(1):61–62 11 Vlatten A, Soder C. Airtraq optical laryngoscope intubation in greater satisfaction during airway management. a 5-month-old infant with a difficult airway because of Robin It is reported by Vlatten et al, wherein a 5-month-old infant sequence. Paediatr Anaesth 2009;19(7):699–700 with Pierre–Robin sequence was successfully intubated using 12 Sbaraglia F, Lorusso R, Garra R, Sammartino M. Usefulness of Airtraq.11 Similarly, a 3-month-old child of Apert syndrome Airtraq in a 3-month-old child with Apert syndrome. Paediatr with difficult airway was intubated with Airtraq.12 Péan et al Anaesth 2011;21(9):984–985 intubated a 10-year-old child, which was a case of difficult air- 13 Péan D, Desdoits A, Asehnoune K, Lejus C. Airtraq laryngoscope for intubation in Treacher Collins syndrome. Paediatr way due to the Treacher Collins syndrome with 5.5 ID armored Anaesth 2009;19(7):698–699 13 tracheal tube using a size-2 Airtraq. Ali et al reported a case 14 Ali QE, Amir SH, Siddiqui OA, Jamil S. Airway management in where they successfully intubated a 3-month-old infant with severe post-burn contracture of the neck using Airtraq: a case occipital meningocele using Airtraq.14 series. Indian J Anaesth 2013;57(6):620–622 Until now, no case report describing the use of Airtraq with adaptor in pediatric hydrocephalus has been discussed in literature.